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The Dreaded Retained Epidural Catheter Tip - Prevention and Management
Abstract Number: S2C-9
Abstract Type: Case Report/Case Series
29 yo G1P0 at 40w2d presented for IOL for decreased fetal movement. PMH was unremarkable. During IOL, patient requested epidural. LOR obtained after 2 attempts with 17G Tuohy, but provider had difficulty threading the 19G wirewound Perifix™ B.Braun catheter. Additional attempts to thread made after rotation of Tuohy and installation of saline. Final attempt to thread met with difficulty withdrawing catheter. Under gentle traction, catheter came out via Tuohy having fractured, missing the 1mm tip. Wirewound portion had not uncoiled, and Tuohy withdrew easily. Patient informed of incident and agreed to placement at a different level. Successful placement followed a right paramedian approach at L3/4. After delivery, lumbar films revealed no fragment. Neurosurgery was consulted and advised no further intervention as long as no signs or symptoms developed. Braun was notified about the incident, and internal event report filed. The patient requested CT despite being advised it would not change management. Radiology read 1mm radiopaque focus left of midline at the S1/2 that could be consistent with the retained tip in epidural space. Again, neurosurgery recommended no intervention or followup, and the patient agreed.
Catheter fragment retention is rare, but real. It can occur during placement due to shearing from the Tuohy, but more described cases are during removal(1,2,3). X-ray is first line, but even CT may miss small radiopaque fragments. MRI is unlikely to be helpful due to slice size and may be contraindicated with a wirewound fragment. Conservative treatment is usual provided no other concerning features are present(2,3). The chief reasons complications could develop include direct mechanical compression onto nerve or cord, fibrotic reaction to fragment, or providing an infectious tract to the skin. Provided no loss of sterile technique, a fragment is itself sterile. Thoracic epidurals, pediatric retained caudal catheters, or concern for intrathecal fragment may warrant aggressive intervention due to cord proximity and chronic but unquantified risks, respectively. The patient should follow-up with their PCP. Red flags include new or evolving motor or sensory deficits, back or radicular extremity pain, changes in urinary or bowel control, fever, or new leukocytosis(3).
Avoiding shearing is best achieved by gentleness whenever difficulty passing or removing the catheter is felt. Removal of Tuohy is indicated to avoid shearing if difficulty encountered placing catheter(4). Avoiding force when met with resistance during catheter removal is crucial. Re-taping the catheter and applying traction later is often successful. Education of anesthesia providers is vital for prevention, but in all cases, the patient can be reassured this extremely rare event is unlikely to pose a problem(3).
1. Anaesth Intensive Care. 2008 Mar;36(2):245-8
2. BMC Anesthesiol. 2015 Jun 4;15:83
3. J Clin Anesth. 2007;19:310–4
4. Int J Obstet Anesth. 2000 Apr;9(2):87-93